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On the last day of the 15th Asia-Pacific Vitreo-retina Society (APVRS 2022) Congress, during an Alconsponsored symposium, experts explored the advantages of longer probe in highly myopic eyes, the benefits of small gauge probes in a retinal survey, as well as the best microscope for the NGENUITY® 3D Visualization System.

Extended long-shaft vitrectomy in myopic eyes

According to Dr. Tzyy-chang Ho from Chinese Taipei, several issues in myopic patients have raised concerns in operations, including increased axial length, epiretinal tissues visualization, dye toxicity, internal limiting membrane (ILM) peeling, macular hole (MH) closure, shaving vitreous tissue, and sclerotomy leakage.

Techniques to deal with such issues involved the use of an optical coherence tomography (OCT) system and a long-shaft probe, he noted.

“The NGENUITY system from Alcon is a 3D digital system with a camera and display that replaces the analog oculars of the scope,” shared Dr. Ho. “There are many advantages of using a 3D head-up viewing system, and one of them is optimizing the surgeon’s ergonomics when using the microscope,” he said, adding that some surgeons had to resort to getting an artificial cervical joint replacement costing 8,000 US dollars each due to musculoskeletal problems.

He mentioned that when carrying out surgery in highly myopic eyes, an extended long-shaft vitrectomy probe provides tissue plane access for eyes with long axial length, enabling the removal of posterior hyaloid, cortical vitreous, and trimming of the ERM and ILM flap in the age of flap surgery.

“There’s no need to remove the cannula or indent sclerotomy to avoid intraoperative complications. Surgical complications of using the extended long-shaft probe are not found in our prospective study,” he said.

He further noted that the extended long shaft vitrectomy probe that is 25 gauge and 30 mm long by Alcon, which can work with the Alcon Constellation system, is created to overcome the issue of a long eyeball in highly myopic patients.

The 30 mm probe can reach the posterior pole better than the previous 27 mm version. “The high gravity brilliant blue green (BBG) and indocyanine green (ICG) can be removed efficiently and faster by the 30 mm probe to prevent extended retinal contact. This probe can be implemented in highly myopic eyes, including those with myopic traction maculopathy, macular hole retinal detachment, macular hole, epiretinal membrane (ERM), and lamellar hole w/o LHEP,” Dr. Ho said.

He showcased a few cases where he used the 30 mm probe, including trimming ILM in eyes with high myopia, ERM in highly myopic eyes, ERM with lamellar hole, and epiretinal proliferation.

“In ERM lamellar hole schisis, only the 30 mm probe can trim the ERM elegantly so that we can preserve proliferative tissue properly,” he concluded, sharing that a 27-gauge probe with a 30-mm-long shaft by Alcon will be available soon.

Benefits of small-gauge retina surgeries

Next, Dr. Adrian Fung from Australia discussed the benefits of smallgauge retina surgeries.

“Small gauge vitrectomy involves the use of 25-gauge (0.55 diameter) and 27-gauge (0.4 mm) probes,” he shared. “The advantages of small gauge vitrectomy include more self-sealing wounds, less sutures are needed, and there will be less inflammation and pain. A smaller gauge also provides greater maneuverability, which is particularly useful in diabetic retinopathy. In addition, a smaller gauge also causes less hypotony due to more self-sealing wounds,” Dr. Fung shared.

Nevertheless, the smaller gauge vitrectomy comes with potential disadvantages, which include decreased vitreous flow, increased port closed time, increased surgery time, and unwanted flexibility.

“The new Hypervit® dual blade vitrectomy probe, however, does have the potential to mitigate some of these limitations due to its features, which include the ability to make 20,000 cuts per minute (CPM), a continuously open port, dual-pneumatic drive, and a bevel tip design,” he said.

He also noted that the Hypervit Dual Blade Probe has a closer port proximity to the retina, and its continuously open port is designed to maximize control through improved efficacy and stability.

“With the Hypervit, we have a continuous vitreous flow rate of up to 90% higher in the 25-gauge probe and up to 48% in the 27-gauge probe (compared to a single-cutting 10,000 CPM probe) because the port is continuously open in the dual-pneumatic drive,” he shared. He added that there is also a reduced peak traction force due to the ability to make 20,000 cuts per minute.

“In terms of surgery time, the 27-gauge vitrectomy only took 90 seconds more than the 23-gauge vitrectomy,” Dr. Fung concluded.

Is Revalia the best match for NGENUITY?

Last but not least, Dr. Kazuhito Yoneda from Japan explored the best microscope for the NGENUITY 3D Visualization System in terms of anterior surgical view, fundus surgical view, and light path comparison.

Five different microscopes are compared in the same operating group and environment: the LuxOR® Revalia™ Ophthalmic Microscope, Microscope A and Microscope B from one company, and Microscope C and Microscope D from another company.

In the anterior segment, Dr. Yoneda and his colleagues compared the transillumination of the microscopes in various situations during cataract surgery. In regard to fundus observation, they compared the width and resolution of the fundus surgical view.

He said Revalia has outstanding performance in all situations during cataract surgery, while the others have reduced transillumination in certain situations.

“The reason Revalia was able to obtain very clear transillumination over a wide area is due to its unique structure, in which the illumination source is located closer to the eyes than the objective lens, hence the light is not concentrated at one point but spread across a wide area of the eye, allowing 6x larger red reflex zone than standard analog microscopes,” he explained.

Besides, Revalia also provides a personalized LED illumination system where one can choose to use either warm white, cold white, or mixed white.

“Theoretically, mixed white can provide both good transillumination and sharp edge in the anterior chamber. But in actual practice, warm white is the best color combination during cataract surgery,” he said.

“In terms of fundus surgical view, Revalia and Microscope D have a very clear and an excellent width of view. Microscope C has a very, very narrow surgical view. Meanwhile, Microscope A is a little narrower than B. As for resolution, there is no difference between the microscopes when using NGENUITY.”

“In clinical use or surgery, it is very important not to have any failed score,” noted Dr. Yoneda. “Revalia and Microscope D can provide excellent fundus image. Revalia is better for anterior surgery, while Microscope D is better for posterior surgery. When comparing microscopes of the same company, a simple microscope is better for NGENUITY,” he noted.

After Dr. Yoneda’s talk, Dr. Maria Berrocal from Puerto Rico joined the panel discussion.

“I use the Revalia and NGEUITY, and I agree with Dr. Yoneda on what he said. I absolutely love the 27-gauge Hypervit probe. I use it for diabetic vitrectomy, and I think that it is very advantageous,” she said.

Editor’s Note

The 15th Congress of the Asia-Pacific Vitreo-retina Society (APVRS 2022) was held on 18-20 November in Taipei, Taiwan. Reporting for this story took place during the event. This article was first published in PIE Issue 24X.